Jonathan Petraglia

Addressing and Interpreting Defense Mechanisms in Psychotherapy: General Considerations

Defense interpretations are commonly used techniques that clinicians employ more frequently than transference interpretations. How and when clinicians interpret defenses, however, has received little empirical examination. In an effort to facilitate the empirical study of defense interpretation, we reviewed 15 works by noted authors who gave a prominent role to interpreting defenses in discussing clinical work in general patient populations. Our goal was to identify and systematize distinct themes from these authors that might be testable hypotheses. We identified 74 themes related to the interpretation of defenses in psychotherapy—for example, “interpreting too frequently diminishes the emotional impact of interpretation”—which we organized into 17 distinct categories (e.g., factors associated with positive outcome). We subsequently selected 19 themes that were readily operationalizable as hypotheses and examination of which would advance clinical practice. These hypotheses address issues such as when, in what order, and how to interpret defensive material and what successful outcomes would be. We then describe prototypes of research designs, employing naturalistic observation, randomized controlled trials, or experimental laboratory studies, which could investigate these important hypotheses. Overall, this report codifies current clinical maxims and then provides future research directions for determining how clinicians can most effectively address defenses in psychotherapy.

Accuracy of Defense Interpretation in Three Character Types

Defense mechanisms are one of the most durable constructs in psychoanalysis and dynamic psychiatry/psychology, spanning theoretical, clinical, and research approaches. While the construct originated with Freud’s 1894 [1] publication, The Neuro-Psychoses of Defence, the first seven decades of psychoanalytic writing largely advanced the theoretical understanding and clinical approaches to defense mechanisms, while the research did not begin in earnest until about the last 40 years, accelerating somewhat more recently. Much of this research has understandably concentrated first on issues of how to assess defenses [2, 3], second, on the relationship of defenses to clinical disorders, such as depression [4] and personality disorders [5, 6], and, third, on change in defenses over time and long-term development [7]. In recent years, this latter avenue has expanded to include treatment outcome studies indicating that defenses and defensive functioning improve with treatment [4, 8–10]. To date, these have been naturalistic observational studies of patients in treatment and follow-up, but they have also begun to examine the role of defenses in the processes of change with psychotherapy. Kramer et al. [11] found that change in distress was mediated by prior improvement during psychotherapy of defensive functioning, but not of conscious coping. Perry and Bond [12] reported that change in defense mechanisms at 2.5 years of long-term dynamic psychotherapy predicted change in multiple measures of symptoms and functioning at 5 years. While we await additional research to establish that change in defenses mediates improvement in symptoms and functioning, it is important to explore and delineate therapeutic processes that lead to change in defenses. This chapter, then, is an effort to examine some early hypotheses and approaches to determining how therapeutic interventions lead to change in defensive functioning within and across psychotherapy sessions.

Ten Principles to Guide Psychodynamic Technique with Defense Mechanisms: An Examination of Theory, Research, and Clinical Implications

Defense mechanisms have stood the test of time as important psychodynamic constructs. Despite their importance, there has been little effort directed at consolidating theory, research, and practice for defense mechanisms. This review aimed to address this gap. More specifically, it aimed to identify and integrate different scholars’ ideas, recommendations or principles on how to address defense mechanisms in therapy. It also aimed to document the existing empirical evidence for these principles and to translate these principles into technical guidelines that clinicians can use. A literature search was completed using PsychInfo, Psychoanalytic Electronic Publishing (PEP), and Medline. Consensual qualitative research methodology was applied to the material retrieved. A set of 10 principles pertaining to working with patient defences was identified.